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09110016 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18630 MEDICUS CT CONTRACTOR:GREAT AMERICAN PERMIT NO:09110016 PLUMBING CO INC r"rNER'S NAME: BEN LAN P O BOX 26942 DATE ISSUED: 11/03/2009 k,,,NER'S PHONE: 4083873340 SAN JOSE,CA 95159 PHONE NO:(408)279-1515 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r— PLUMB r License Class Lic. r r MECH RESIDENTIAL COMMERCIAL Contractor(.Ra4T JVk q Cilill Date l L3 b JOB DESCRIPTION:REPLACE SEWER NE INSTALL PROPERTY I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions LINE CLEAN Code and that my license is in full force and effect. OUT I hereby affirm under penalty of perjury one of the following two declarations: 1 have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the y performance of the work for which this permit is issued. ,x, I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Flo 6 rea',', r Valuation:$5000 Section 3700 of the Labor Code,for the performance of the work for which this € , permit is issued. - , A�N Nm" a 375 011.00 Occupancy Type: APPLICANT CERTIFICATION Iot I certify that 1 have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued y• Dater/` 3 S ,�ture Date f�" _O ❑ 'OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the stricture is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& 1 have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I O er r ed a a become subject to the Worker's Compensation provisions of the Labor Code,I must Date:t/ 3 '� 'fes forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter I 'he above mentioned property for inspection purposes.(We)agree to save Lender's Address nify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37526011 .00 DATE ISSUED. . . . . . . : 11/03/2009 RECEIPT #. . . . . . . . . : BS000009112 REFERENCE ID # . . . : 09110016 SITE ADDRESS . . . . . : 18630 MEDICUS CT SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER BEN LAN ADDRESS . . . . . . . . . . : 18630 MEDICUS CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : THE GREAT AMERICAN CONTRACTOR . . . . . . . : CORPORATION LIC # 18061 COMPANY GREAT AMERICAN PLUMBING CO INC ADDRESS P O BOX 26942 CITY/STATE/ZIP . . . : SAN JOSE, CA 95159 TELEPHONE (408) 279-1515 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 5, 000. 00 1 . 00 0. 00 1 . 00 0 . 00 1BSEISMICR VALUATION 5, 000 . 00 0 .50 0. 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1PRSEWER UNITS 1 . 00 21 .00 0 . 00 21. 00 0 . 00 1TRAVDOC FLAT RATE 1. 00 42 .00 0 . 00 42 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 106 .50 0 . 00 106 .50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 106 .50 #112332 --------------- TOTAL RECEIPT 106 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING oq � i ... CITY OF CUPERTINO ' REPIPE/SEWER/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN# U Date: 3�_o 77 Building Address: 30 WQ31 c xAs C Owner's Name: Phone#: CA AJ -31is-1 -33 Contractor: Phone#: Fax#: — 3 Contact: Phone#: Jsasa�l Fax #: Contractor License#: 'j 1 �� Cupertino Business License#: Job Description: ke IF < JAi E CLQ v u� Residential N� Commercial ❑ Valuation: 5600 00 Project Size: Express dard Large ❑ Major Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set& the sheet index. Green Building Points: Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial building P ICPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System P 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1 BSEISMICOM Seismic Commercial P Revised 01/07/09 " CITY OF CUPERTINO r REPIPE/SEWER/MAIN SERVICE CITY OF CUPEI,TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group f 1 BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES / 1 BSEISMICR Seismic Residential p 1PRSEWER Residential building P 1RPSS sewer/sanitary sewer 1PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1 PPRSEWG Private Sewage Disposal System P 1 PCESS Cesspool p 1 BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture p IPGASRES Residential Gas Piping System P 1-4 Outlets 1 BPGAS Gas Piping System 5+ Outlets P / 1 PPERMITFEE Plumbing Permit Fee Issuance P 1 PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B M.Indoor Air Quality and Finishes I.uselONNO-VOc Paw 1 IAQ/Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0 3.Use Lowft VOCAdhosiues 3 IAQ/Health pts y=yes p 4.Use Salvaged Materials for Interior Finishes 3 Resource pts y--yes 0 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 61AQ/Health pts y=yes p 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0 7•Se�i!»IIFed '.exite�board�r 41AQ/Health. pts y=yes 0 8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0 9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0 10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0 1 1 1 N.Flooring 1.Select FSC Certified Wood Flooring B Resource pts y=yes 0 2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0 3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0 5.Use Exposed Concrete as Finished Floor 4 Resource pts y--yes 0 6.Install Recycled Content Carpet with Low VOCs 4 Resource pts Ayes p 1 1 1 Total Points Available: 1 1401 130 57 Total Points Project Received: 0 —OF-0 G:data/progs/greenbuildngguidelines/remodelers/greenpointsfinal2.12.04protected.xls Community Development 10300 Torre Avenue sa . Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ,;UPEkTINO Building Department JOB ADDRESS: PERMIT # 571. 01?X U b� OWNER'S NAME: LAA, PHONE # g71'-157,5- GENERAL 7 -1 ,S'GENERAL CONTRACTOR: # -( 17 I am not using any subcontractors: P-3 V F Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date